Although antiepileptic drugs (AEDs) are used to treat a spectrum of psychiatric disorders, in some instances they are prescribed without clear evidence of clinical benefit or safety. When considering prescribing an AED, ask yourself:

Does the evidence show the drug is efficacious for my patient’s disorder or symptoms?

Which adverse effects are associated with this medication?

What are the advantages of monitoring the patient’s serum drug concentration?

This review provides an evidence-based framework regarding the safe and effective use of AEDs in psychiatric patients.

Although selective serotonin reuptake inhibitors (SSRIs) are frequently prescribed and are better tolerated than older antidepressants, side effects such as sexual dysfunction limit patient acceptance of these medications. DSM-IV-TR categorizes medication-induced sexual dysfunction as a type of substance-induced sexual dysfunction. These dysfunctions are characterized by impairment of various sexual response phases.

Estimating the true incidence and prevalence of SSRI-related sexual dysfunction can be difficult. Zimmerman et al compared psychiatrists’ clinical assessments of depressed patients receiving ongoing treatment with results of a standardized side effects questionnaire and found that even though psychiatrists regularly inquired about sexual side effects, on the questionnaire patients reported higher rates of almost all sexual dysfunctions. The incidence of SSRI-induced sexual dysfunction also can be difficult to ascertain because some sexual dysfunctions frequently accompany a primary psychiatric disorder or physical illness. Balon suggested that the incidence of SSRI-associated sexual dysfunction is 30% to 50%, although others have reported higher incidences.

A large number of individuals contribute in many ways to the process of discovering, applying, and disseminating new psychiatric knowledge. I am, of course, referring to researchers, clinicians, teachers, and advocates who touch the lives of millions of persons who suffer from mental illness every year. This editorial is dedicated to singing the praises of those who quietly contribute to advancing psychiatry.

Patients. Tens of thousands of psychiatric patients sign an informed consent form and volunteer to participate in clinical trials to test new drugs in double-blind, placebo-controlled studies that could lead to FDA approval. Without these volunteers, it would be almost impossible to develop new medications.Research assistants. They are an army of skilled technical workers who do the heavy lifting in animal or human research and put in long hours to collect data or conduct tests. Yet they are rarely recognized for their critical contributions to science and clinical practice.

The brain is an electrochemical organ, and its activity can be modulated for therapeutic purposes by electrical, pharmacologic, or combined approaches. In general, neuromodulation induces electrical current in peripheral or central nervous tissue, which is accomplished by various techniques, including:

electroconvulsive therapy (ECT)

vagus nerve stimulation (VNS)

transcranial magnetic stimulation (TMS)

deep brain stimulation (DBS).

It is thought that therapeutic benefit occurs by regulating functional disturbances in relevant distributed neural circuits. Depending on the stimulation method, the frequencies chosen may excite or inhibit different or the same areas of the brain in varying patterns. Unlike medication, neuromodulation impacts the brain episodically, which may mitigate adaptation to the therapy’s beneficial effects and avoid systemic adverse effects.

Neuromodulation techniques are categorized based on their risk level as invasive or noninvasive and seizurogenic or nonseizurogenic. Although these and other approaches are being considered for various neuropsychiatric disorders, the most common application is for severe, treatment-resistant depression. Therefore, this article focuses on FDA-approved neuromodulation treatments for depression, with limited discussion of other indications.

Parricide—killing one’s parents—once was referred to as “the schizophrenic crime,” but is now recognized as being more complex. In the United States, parricides accounted for 2% of all homicides from 1976 to 1998, which is consistent with studies from France and the United Kingdom. Parricide’s scandalous nature has long attracted the public’s fascination.

This article primarily focuses on the interplay of the diagnostic and demographic factors seen in adults who kill their biological parents but briefly notes differences seen in juvenile perpetrators and those who kill their stepparents. Knowledge of these characteristics can help clinicians identify and more safely manage patients who may be at risk of harming their parents.

Psychological distress among patients with breast cancer is common and is linked to worse clinical outcomes. Depressive and anxiety symptoms affect up to 40% of breast cancer patients, and depression is associated with a higher relative risk of mortality in individuals with breast cancer. Psychotropic medications and psychotherapy used to treat depression in patients without carcinoma also are appropriate and effective for breast cancer patients. However, some patients present distinct challenges to standard treatment. For example, growing evidence suggests that some selective serotonin reuptake inhibitors (SSRIs) may reduce the effectiveness of tamoxifen, a chemotherapeutic agent. This article discusses challenges in diagnosing and treating depression in breast cancer patients and reviews evidence supporting appropriate psychiatric care.

One of the basic psychiatric principles accepted by all practicing psychiatrists is that a delusion is a fundamental symptom of psychosis.

A delusion is defined as “a fixed false belief not commensurate with the person’s educational and cultural background” and is almost universally associated with schizophrenia and other psychotic disorders. But if we apply the notion that a fixed false belief is delusional, then several “nonpsychotic” psychiatric disorders would qualify as psychoses based on their core clinical symptoms, including major depressive disorder, obsessive-compulsive disorder, anxiety disorders, and others.

The number of people with psychiatric disorders who use complementary and alternative medicine (CAM) is on the rise. In surveys of patients seeking psychiatric care, estimates of CAM use range from 8% to 57%; the most frequent uses are for depression and anxiety disorders. A population-based study in the United States found that 9% of respondents had anxiety attacks and 57% of these individuals had used CAM. Similarly, in a Finnish population-based study (N=5,987) 35% of subjects reported some form of CAM use in the previous year; those with comorbid anxiety and depressive disorders used CAM most frequently.

Unfortunately, a MEDLINE search shows that the number of studies examining psychotropic medications dwarfs the number of studies on even the most common CAM treatments used for psychiatric disorders. Far more patients with diagnosed mental disorders are studied in trials of standard treatments than CAM treatments. Because very few studies evaluate the cost-effectiveness of CAM treatments for psychiatric disorders, the risk-to-benefit ratio is difficult to calculate. Although several CAM treatments for depressive disorders have enough support to be considered options,CAM options for anxiety disorders are fewer and have less evidence of efficacy.

Hallucinations in children are of grave concern to parents and clinicians, but aren’t necessarily a symptom of mental illness. In adults, hallucinations usually are linked to serious psychopathology; however, in children they are not uncommon and may be part of normal development.

A hallucination is a false auditory, visual, gustatory, tactile, or olfactory perception not associated with real external stimuli. It must be differentiated from similar phenomenon such as illusions (misperception of actual stimuli), elaborate fantasies, imaginary companions, and eidetic images (visual images stored in memory).

Barbara Stuart, PhD, Staff psychologist, Department of psychiatry, University of California, San Francisco, San Francisco, CA

Kate Hardy, ClinPsychD, Postdoctoral fellow, Department of psychiatry, University of California, San Francisco, San Francisco, CA

Rachel Loewy, PhD, Assistant professor, Department of psychiatry, University of California, San Francisco, San Francisco, CA

“I haven’t wanted to call it psychosis yet…”“I’m not sure if this is psychosis or neurosis.”“I wonder if there’s a psychotic process underneath all of this?”“Psychotherapy won’t help psychosis.”

In our experience as practitioners in an early psychosis program, the above statements are common among mental health care providers. In our opinion, they are examples of vestiges of an archaic, overly simplistic clinical language that is not representative of current conceptions of psychosis as being on a continuum with normal experience.

The above quotes speak of psychosis as an all-or-none distinction: a “switch,” something fundamentally different from other psychological processes. In this article, we highlight common “all-or-none” myths about psychosis and argue for a more fluid, normalized psychosis language, where impairment is defined not by the absolute presence or absence of “weirdness” but instead by distress, conviction, preoccupation, and behavioral disturbance. We challenge the notion that the presence of psychosis mandates a “fast track” diagnosis that ignores the complexity of human experience.

Thursday, September 30, 2010

As a National Institutes of Health-trained psychopharmacologist who also received substantial psychotherapy training during residency, I value both as pillars of psychiatric practice.

However, often I think about the evidence-based conduct of psychotherapy, which I regard as a neurobiologic treatment similar to drug therapy, and then I ask research questions that remain unanswered, such as:

What is the therapeutic “dose” of psychotherapy? Does it differ by type of therapy or the patient’s diagnosis?

Is the dose measured in the number of sessions or the time the patient is in a therapy session? Is there a loading dose? What is the maintenance dose?

What is the optimal schedule for psychotherapy? By what established criteria does a therapist determine how often to administer psychotherapy? Why weekly and not daily? Why not 2 or 3 times a day intensive psychotherapy for acutely ill patients? Is the scheduling based on the cost to the patient, the therapist’s availability, or insurance coverage rather than the patient’s needs?

Mehrzad Seraji, MD, Fellow, Department of neurology and psychiatry, Division of geriatric psychiatry, St. Louis University School of Medicine, St. Louis, MO

Maurice Redden, MD, Instructor, Department of neurology and psychiatry, Division of geriatric psychiatry, St. Louis University School of Medicine, St. Louis, MO

Ramasubba Tatini, MD,Private practice, St. Louis, MOThe number of older adults (age ≥65) who developed schizophrenia before age 45 is expected to double in the next 2 decades; the 1-year prevalence of schizophrenia among older adults is approximately 0.6%.This article reviews how positive, negative, and cognitive symptoms and social functioning change over decades and discusses strategies for reducing the impact of long-term antipsychotic use on neurologic and physical health. Although some patients experience schizophrenia onset later in life, in this article we focus on older adults who developed the illness before age 45.

Robert M. Anthenelli, MD, Current Psychiatry Section Editor for substance use disorders, is professor of psychiatry, psychology, and neuroscience, director of addiction sciences division and Tri-State Tobacco and Alcohol Research Center, University of Cincinnati College of Medicine, and director of Substance Dependence Program, Cincinnati Veterans Affairs Medical Center, Cincinnati, OH.

Eugene Somoza, MD, PhD,Professor of clinical psychiatry, University of Cincinnati College of Medicine, and director of the Cincinnati Addiction Research Center, Cincinnati, OH.

Unlike opioid or alcohol abuse, for cocaine dependence there are no FDA-approved pharmacotherapies, which leaves psychosocial treatment as the standard of care for the estimated 1.6 million individuals in the United States who abuse cocaine. However, researchers are developing a novel way to help cocaine-dependent patients reduce their drug use. Therapy for addiction–cocaine addiction (TA-CD) is thought to curb cocaine use by engaging the body’s immune reaction and stopping cocaine molecules from reaching the brain, thereby reducing the drug’s pleasurable effects.

One researcher working on this vaccine, Eugene Somoza, MD, PhD—the principal investigator of the Ohio Valley Node of the National Institute on Drug Abuse clinical trials network of 16 universities and treatment programs—discusses with CurrentPsychiatry Section Editor Robert M. Anthenelli, MD, how TA-CD works and how it might be used in clinical practice.Read full text (free access)

As a specialty that deals with brain disorders, psychiatry is now much more integrated with other medical and surgical specialties than in the past. Psychiatry is no longer perceived as a ‘different’ discipline and has successfully embraced the medical model without abandoning its biopsychosocial principles.

But some chasms remain and several separations persist, impacting not only the image of the specialty but also psychiatrists and their mentally ill patients. Some issues need to be addressed before full integration can occur.

The high prevalence of substance use disorders (SUDs) in persons with bipolar disorder (BD) is well documented. Up to 60% of bipolar patients develop an SUD at some point in their lives. Alcohol use disorders are particularly common among BD patients, with a lifetime prevalence of roughly 50%. Recent epidemiologic data indicate that 38% of persons with bipolar I disorder and 19% of those with bipolar II disorder meet criteria for alcohol dependence. Comorbid SUDs in patients with BD are associated with:

poor treatment compliance

longer and more frequent mood episodes

more mixed episodes

more hospitalizations

more frequent suicide attempts.

The impact of co-occurring SUDs on suicidality is particularly high among those with bipolar I disorder. Frequently referred to as “dual diagnosis” conditions, co-occurring BD and SUDs may be more accurately envisioned as multi-morbid, rather than comorbid, illnesses.

John Peterson, M, Director, child and adolescent psychiatry, Denver Health Medical Center, Associate professor, Department of psychiatry, University of Colorado School of Medicine, Denver, COStacey Freedenthal, PhD, Associate professor, Graduate School of Social Work, University of Denver, Denver, CO

Adam Coles, MD, Resident Department of psychiatry, University of Colorado School of Medicine, Denver, CO

Josh, age 16, gets poor grades in school and occasionally smokes marijuana and abuses inhalants. After his girlfriend breaks up with him, he cuts his wrist with a hunting knife. While bleeding profusely, Josh calls his mother at work, who calls 911. The cut is deep and requires sutures. Josh says he did not try to kill himself; he only wanted to carve his girlfriend’s initials into his wrist to show his love for her.

When treating teenagers with self-harming thoughts and behavior, it may be difficult to distinguish suicide attempts from self-injury without intent to die. Understanding adolescent self-harm, suicide risk assessment, and treatment options guides clinicians to appropriate interventions. Recognizing the need for aggressive treatment—including psychiatric hospitalization—is essential to keeping self-harming teenagers safe.

Depression in older adults (age ≥65) can devastate their quality of life and increase the likelihood of institutionalization because of behavioral problems. Depression is a primary risk factor for suicide, and suicide rates are highest among those age ≥65, especially among white males. The burden of geriatric depression can extend to caregivers. Prompt recognition and treatment of depression could help minimize morbidity and reduce suffering in older adults and their caregivers.

Although geriatric depression varies in severity and presentation, common categories include:

major depressive disorder (MDD)

vascular depression

dysthymia

depression in the context of dementias, psychosis, bipolar disorder, and executive dysfunction.

Diagnoses in this population generally correspond with DSM-IV-TR criteria, but geriatric depression has distinct clinical manifestations.

Personalized care is at the heart of good medical care. It is an indispensable ingredient for optimal clinical outcomes because each patient is unique, as an individual and as a patient, and requires customized treatment.

If 10 patients with depression walk into a psychiatrist’s office on any given day, each will be different and should be treated accordingly. Their symptoms may be similar thematically but they differ widely in presentation and content. Their medical and psychiatric histories and social, educational, religious, ethnic, socioeconomic, and attitudinal diversity can be stunning in complexity and disparity. Just as patients’ symptoms can be similar yet different, so can their response to a specific antidepressant or psychotherapy. Their clinical and functional outcomes will vary widely in degree and valence. Every psychiatrist expects (and enjoys) the richness of patient backgrounds and manages each individually.

Given these individual differences among our psychiatric patients, why are practitioners being barraged by various entities to abandon the traditional medical approach to their patients? Why is there a push to transform personalized clinical care to an assembly-line system, where patients are defined by their disease and are managed like “human widgets” as though they can be “processed” in an identical, protocolized, mechanical manner? This is completely antithetical to the magnificent personal approach inherent in the classic and highly effective doctor-patient relationship.

Compared with men, women have a 1.3- to 1.8-fold greater risk for developing insomnia. Multiple factors contribute to this increased risk of insomnia, including:

hormonal changes across the reproductive cycle

predilection to mood and anxiety disorders

psychosocial factors, such as being single, separated, or widowed.

Furthermore, the higher prevalence of psychiatric disorders during the reproductive stages may confer additional risk for sleep problems.

Insomnia has tremendous impact on health and quality of life, resulting in reduced work productivity and increased absenteeism, accidents, and health care costs. This article examines the factors that contribute to women’s sleep difficulties throughout the life cycle, and suggests evaluation and treatment approaches appropriate for each phase.

Jess G. Fiedorowicz, MD, MS, Assistant professor, Departments of psychiatry and epidemiology, Roy A. and Lucille J. Carver College of Medicine, College of Public Health, University of Iowa, Iowa City, IA

William G. Haynes, MD, Professor, Department of internal medicine, Institute for Clinical and Translational Science, Roy A. and Lucille J. Carver College of Medicine, University of Iowa, Iowa City, IA

Does low cholesterol predispose to depression and suicide, or vice versa? A growing body of literature examining the putative links among cholesterol, mood disorders, and suicide has produced inconsistent findings and unclear clinical implications that may leave psychiatrists unsure of how to interpret the data. Understanding cholesterol’s role in mood disorders may be relevant to the 2 primary causes of excess deaths in patients with mood disorders: suicide and vascular disease health.

Few things capture the imagination like the future. I recall how after reading Alvin Toffler’s seminal book Future Shock in college, I was fascinated by how the future could change us as people and as a culture.

During medical school and psychiatric residency, the breathless pace of scientific discoveries—especially in neuroscience—prompted me to dream about the potentially stunning medical breakthroughs of the future. My frustrations about severe, disabling psychiatric brain disorders were tempered by hope that tomorrow will unfold new knowledge that will unravel the dark mysteries of psychotic delusions, obsessive-compulsive disorder (OCD) rituals, intractable narcissism, suicidal urges, and homicidal impulses. The future, I frequently mused, will provide all answers for definitive diagnoses, effective treatments, prevention, and cures for all psychiatric disorders.

Hope for restoring wellness for our suffering patients continues to sustain me and my fellow psychiatrists. The ongoing gush of neuroscience advances that elucidate the divine details of brain and mind continue to inspire us. However, we are getting impatient with the slow translation of groundbreaking basic science discoveries into new and dramatic clinical applications for our long-suffering patients. A collective mantra is building up: We want our future and we want it now!

Evolving advances are lurking in our future, some of which already are palpable and we hope may soon become clinical realities liberties.

Monday, June 7, 2010

Nazem Bassil, MD, Fellow, Division of geriatric psychiatry, St. Louis University School of Medicine, St. Louis, MO

George T. Grossberg, MD, Samuel W. Fordyce Professor, Department of neurology and psychiatry, St. Louis University School of Medicine, St. Louis, MO

Pharmacologic treatments for Alzheimer’s disease (AD) may improve symptoms but have not been shown to prevent AD onset. Primary prevention therefore remains the goal. Although preventing AD by managing risk factors such as age or genetics is beyond our control, we can do something about other factors.

This article summarizes the findings of many studies that address AD prevention and includes an online-only bibliography for readers seeking an in-depth review. The evidence does not support a firm recommendation for any specific form of primary prevention and has revealed hazards associated with estrogen therapy and nonsteroidal anti-inflammatory drugs. Most important, it suggests that you could reduce your patients’ risk of developing AD by routinely supporting their mental, physical, and social health.

As physicians, recognizing impairment in our colleagues or ourselves can be difficult. The American Medical Association defines an impaired physician as one who is unable to fulfill personal or professional responsibilities because of psychiatric illness, alcoholism, or drug dependence. Impairment is present when a physician is unable to perform in a manner that conforms to acceptable standards of practice, exhibits serious flaws in judgment, and provides incompetent care.

Recognizing when a physician is impaired, deciding whether to report him or her to the state medical board, and referring a colleague for treatment can be challenging. This article will:

review substance abuse, cognitive decline, and other causes of impairment

address legal and ethical issues involved in reporting a colleague to the state medical board

Do lawyers understand psychiatry? To answer that semi-rhetorical question, I imagined the following conversation between 2 friends, Barry the barrister and Harry the psychiatrist.

Barry: Harry, I think psychiatry is a politically incorrect discipline.

Harry: How so, my dear friend?

Barry: Well, psychiatrists hospitalize people against their will, strip them of their civil liberties, and force them to take powerful, mind-altering drugs.

Harry: Barry, when you think about it objectively, involuntary hospitalization is a compassionate and legal act for people suffering from a brain disease that makes them suicidal or homicidal and a danger to themselves and others with no insight that they are sick. Once treated and improved, patients regain their civil liberties and often thank us for providing care against their will. And a person needs a healthy brain to properly exercise one’s civil liberties.

Few topics are as controversial as the role of antidepressants for patients with bipolar disorder. Although depression usually is the predominant, most enduring mood state in bipolar disorder, clinicians often face uncertainty about using antidepressants because of concerns about safety and efficacy. Whether and when to use antidepressants for bipolar depression hinges on complex parameters that preclude any single, simple rule.

Rather than asking if antidepressants are useful or detrimental for depressed patients with bipolar disorder, a more practical question might be: Under what circumstances are antidepressants likely to be beneficial, deleterious, or ineffective for an individual patient? Because “real world” patients often have idiosyncrasies that defy practice guidelines’ generic treatment recommendations, clinicians who practice in the proverbial trenches need strategies to tailor treatments to each patient that are informed—but not dictated—by evidence-based research.Read full text (free access)

Both men and women respond well to antidepressants, yet there are notable differences between the 2. Understanding why men and women may differ in response to antidepressants helps clinicians better tailor their treatment choice and dosing.

This article outlines some of differences—and lack thereof—in response rates to antidepressants. Our discussion of why these differences may occur is framed in the context of pharmacokinetics, pharmacodynamics, and the influence of gonadal hormones on antidepressant-related neurotransmitter systems. The second section focuses on major reproductive phases of adult women (the menstrual cycle, pregnancy, postpartum, and menopause) and how antidepressant response rates can influence clinical decision making, such as antidepressant timing, dose, and choice of potential adjunct treatments.

Although psychiatrists commonly combine psychotropic medications, researchers malign the practice as “not evidence-based.” Research is finally catching up with clinical practice, however, and evidence is rapidly accumulating that for many patients with severe psychiatric disorders, 2 drugs are better than 1.

This should not be surprising because “real world” patients with schizophrenia, bipolar disorder, major depression, anxiety disorders, or obsessive-compulsive disorder (OCD) often do not achieve remission and are hobbled—even disabled—by their illness without combination therapy. The same principle holds true for general medical illnesses such as hypertension, cancer, or diabetes, where combination therapy is the norm rather than the exception.

Recent studies have confirmed better efficacy with combination therapy compared with monotherapy for several psychiatric illnesses.

Leslie Citrome, MD, MPH Professor of PsychiatryNew York University School of Medicine

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Benzodiazepines are the mainstay of alcohol detoxification treatment, with extensive evidence supporting their efficacy and relative safety. The risk of benzodiazepine-alcohol interaction, however, and psychomotor and cognitive impairments associated with benzodiazepine use may limit early rehabilitation efforts in hospitalized patients. Cross-tolerance with alcohol also limits benzodiazepines’ potential benefit in outpatients with substance use disorders.

Although not all studies endorse adding anticonvulsants to benzodiazepines for managing alcohol withdrawal syndrome (AWS), we present 3 cases in which anticonvulsants were used successfully as adjuncts to lorazepam. Valproic acid, levetiracetam, and gabapentin offer advantages in acute and long-term therapy of alcohol dependence with efficacy in AWS, low abuse potential, benign safety profile, and mood-stabilizing properties.

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